Once the agreements for environmental change have been made in a formal manner using the tables described in chapter 3, or in an informal unwritten way which is probably more common, there needs to be a plan to implement those changes that are considered most important. This involves identifying the core environmental needs that are likely to influence many of the others if they are satisfied. This is one of the difficult parts of nidotherapy – it is not too difficult to get a list of apparent needs that are desired with greater or lesser enthusiasm, but identifying which are the core ones if someone has dozens is not an easy task. Thus a woman with constant need for support and encouragement may list a great number of individual needs such as contact with members of her family, regular meetings, being accompanied to shops and other places, holidays together, support when dealing with official matters, and the general needs for company. These cannot all be met as it would involve many people who have no particular desire to be involved regularly, providing support around the clock or at times to suit the individual rather than themselves, and there could be danger that they will repeatedly come into conflict with each other by making different arrangements. Together with the patient, the nidotherapist has to distil these needs into a practical and feasible way of providing the support that is needed and, once identified, this has to be confirmed with the individuals concerned to ensure that it is both feasible and viable in the longer term.

Often there may be considerable doubt about the best way of achieving these needs and in such cases it is often reasonable to test out suggestions before deciding on the best way forward.

Environmental tests

Environmental testing is similar to behavioural interventions in cognitive and behaviour therapy except that it is the environment being tested more than the patient's attitudes or behaviour directly. The essential elements involved in the environmental test are listed in Box 4.1.